Gliederung

Introduction: Retrospective studies and meta-analysis have shown a significant reduction of postoperative pancreatic fistula (POPF) with pancreatogastrostomy (PG) compared to pancreatojejunostomy (PJ) for reconstruction after pancreatoduodenectomy. So far only one of four randomized trials (RT) could verify this finding. In the setting of a soft pancreas, pancreatogastrostomy is associated with significantly reduced surgical complications.

Materials and methods: From 2006 to 2011, n=116 patients were randomized intraoperatively to receive a PG or PJ. PJ was performed by duct-mucosa anastomosis with pancreatic duct stenting, PG by internal pursestring and single interrupted suture via anterior and posterior gastrotomy. Primary endpoint was POPF of Grade B or C (ISGPS definition). Secondary endpoints included postpancreatectomy hemorrhage (PPH, ISGPS definition), reoperation and mortality. A planned subgroup analysis was performed for patients with critical and soft pancreas.

Results: ITT analysis comprised 59 PG and 57 PJ. Demographic and risk factors were balanced in the treatment arms. The rate of POPF B/C in the PG vs PJ arm was 12% vs 10% (p = not significant (n.s.)). In the high-risk subgroup with soft pancreas (n=64), the POPF B/C rate was lower with PG compared to PJ (24% vs 14%, p = n.s.). Postoperative bleeding rates (PPH Grade B or C) were not statistically different (PG vs PJ, 10% vs 7%, p=n.s.). Intraluminal bleeding occurred more frequently with PG (7% vs 2%, p=n.s.) and required reoperation in one patient. Mortality was very low (1.8%) in both groups and was associated with complications of POPF in patients with soft pancreata.

Conclusion: Mortality of pancreatoduodenectomy is low but still associated with complications of POPF, therefore the question of safety in pancreatoenteric anastomosis remains important. The trial did not detect a statistically significant difference between PG and PJ in terms of POPF rate but validates retrospective data including a trend towards reduced POPF in high-risk patients. These findings need to be confirmed in the setting of a high-volume randomized trial.